• Implementation of Alcohol Screening, Brief Intervention, and Referral in Primary Care

      Kelso, Shannon M.C.; Wiseman, Rebecca Fortune (2019-05)
      Background: Excessive alcohol use is associated with many short- and long-term health risks. The U.S. Preventive Services Task Force recommends that all adults age 18 and over be screened for alcohol misuse in a primary care setting and that those who display risky or hazardous drinking receive brief counseling interventions. However, only around half of primary care providers report screening patients for substance use, with even fewer providing brief interventions or referrals to treatment. Local Problem: A mobile primary care clinic in Maryland serves an uninsured, immigrant, primarily Hispanic population. The majority of patients speak Spanish with limited English proficiency. Prior to this project, there was no formal protocol in place for alcohol screening. Patients were intermittently screened with an informal question, with no evidence-based screening tool or plan for intervention or referral in use. Interventions: The purpose of this quality improvement project was to pilot the implementation of a protocol for alcohol screening using the Alcohol Use Disorders Identification Test (AUDIT) and its short form (AUDIT-C), brief intervention consisting of simple advice, and referral to treatment (SBIRT). The project was implemented over a 15-week period. Inclusion criteria for screening included all new intake patients age 18 or older with no cognitive impairment and the ability to understand and speak English and/or Spanish. The University of Maryland Baltimore Institutional Review Board provided a Non-Human Subjects Research determination for project implementation. Included patients were screened according to the SBIRT protocol. The AUDIT-C was administered by the staff member assisting the patient with admission paperwork. In the event of a positive score on the AUDIT-C, the provider screened the patient with the remaining questions of the AUDIT. For patients with positive scores on the AUDIT, the provider then delivered a brief intervention and referral to community resources. Data collection was conducted via weekly chart audits throughout the pilot period. Results: Of the new intake patients meeting inclusion criteria (n=46), 97.8% (n=45) were screened with the AUDIT-C according to the protocol. Of these, 6.7% (n=3) scored positive for risky drinking. All patients with positive scores were screened with the full AUDIT, and 2 (66.7%) were documented as receiving an intervention. While no referrals were documented, conversations with staff indicated that referrals were given to these patients but not documented. Conclusions: The results demonstrated the feasibility of incorporating an alcohol SBIRT protocol into a mobile primary care clinic. The clinic staff felt the SBIRT protocol improved alcohol screening and confidence in handling patients with risky drinking behaviors, and they intend to continue utilizing the alcohol SBIRT protocol to screen all new intake patients. The clinic director plans to integrate the SBIRT tools into the clinic’s electronic health record, which is expected to improve documentation, and to ultimately initiate annual screening of existing patients using the alcohol SBIRT protocol to further improve behavioral health integration and improve quality of care.
    • Implementation of Depression Screening in a Primary Care Practice

      Flores, Jacqueline N.; Davis, Alison D. (2021-05)
      Problem & Purpose: Depression is a common mood disorder that affects over 19.4 million adults annually in the United States. Depression is a leading cause of disability, absenteeism, and suicide. Primary care providers can diagnose and treat depression; yet, 50% of all depression diagnoses are missed in the absence of effective screening. Clinical practice guidelines support routine use of the Patient Health Questionnaire-9 depression screening tool among primary care patients. The purpose of this quality improvement project was to implement and evaluate the effectiveness of depression screening using the Patient Health Questionnaire-9 among adult patients at a suburban primary care clinic. Methods: The project was implemented by a team of primary care providers and nurse practitioner students during a 12-week period beginning in September of 2020. Staff and students received education on the importance of depression screening and intervention prior to implementation. Participants included primary care patients ages 18 or older who could speak and understand English, presenting for sick- or well-visits, either in-person or through telehealth. Participants were asked to complete the Patient Health Questionnaire-9 prior to their visit. Each patient’s sum score was calculated to determine presence of depression, severity, and assign corresponding interventions: watchful waiting, counseling referral and/or pharmacotherapy referral. Screening rates, specific scores, intervention rates, and specific interventions were collected weekly through chart audit and review of Patient Health Questionnaires. Results: Clinic personnel screened 61.3% (n=233) of eligible patients and 18.5% of these patients (n=43) had scores > 5 requiring intervention. All patients identified with depression were offered an intervention, of which 86% (n=37) accepted intervention and 14% (n=6) refused. Conclusions: The implementation of Patient Health Questionnaire-9 screening may increase rates of depression identification and facilitate treatment. Routine depression screening in primary care settings may guide patient management, staging of depression, and corresponding treatment plans.
    • Implementing Mobile Text-messaging to Improve Attendance at Well Visits in Primary Care Pediatrics

      Osuagwu, Ngozi E.; Connolly, Mary Ellen (2019-05)
      Background: Missed appointments are a long-standing problem encountered both in the United States and abroad with rates ranging anywhere from 5% to 55%. It is a major cause of inefficiency in the medical system and consequences include poor health outcomes, wasted health care dollars, waste of provider time and adverse effect on patient -provider relationship. Local Problem: No-shows are a significant problem in primary care especially in underserved populations. The implementation site for this quality improvement project provides care to an underserved population with a no-show rate of 35%. The purpose of the DNP quality improvement project was to implement and evaluate the use of mobile text messaging to reduce the non-attendance rate to routine well visits in a primary care pediatric clinic in inner city Baltimore. There is evidence to support the use of text message reminders to improve both medication adherence and attendance rates when compared to other available appointment reminder systems. Intervention: The project was implemented in a sample of patients by nurses, front office staff and providers. The intervention involved sending text message appointment reminders to patients. The attendance rate was later analyzed and compared to the attendance rate prior to the implementation period. Inclusion criteria for the patient population was patients aged 18 years and older or the legal parent or guardian of a patient who was under the age of 18 years. Staff attended a 4-hour training session, which was led by the project leader and I.T. personnel. A preimplementation survey was conducted to determine patients’ and parents’ perception of the planned mobile text-messaging system. The questionnaire was quantified, averaged and the result was favorable. During the implementation period, data was collected that reflected the rate of attendance during the project. This information was aggregated and stored by the EHR system. Data was retrieved from the EHR and Run charts were used for data analysis. Results: The attendance data from the intervention showed that there was no significant increase in attendance to well visits for October, November and December compared to the preceding months of July, August, and September 2019. Conclusions: Though the result of the intervention did not reflect the expected impact, several lessons were learned. There were some positive unexpected findings, including an increase in portal registration, improvement in the update of patient phone numbers in the EHR database, and greater rapport among staff due to teamwork.
    • Implementing Posttraumatic Stress Disorder Screening, Brief Intervention, and Referral in Primary Care

      Weston, Tarleen K.; Wiseman, Rebecca Fortune (2019-05)
      Background: Posttraumatic Stress Disorder (PTSD) has a prevalence of 8.7% in the United States. This disorder is associated with increased social, occupational, and physical impairments which lead to increased healthcare utilization and expense. Ethnic minorities, individuals with inadequate social support, those of low-income, and urban residents are at greater risk of developing PTSD. Identifying PTSD in the primary care setting can lead to improved overall patient health, improve overall population health, and alleviate the economic and healthcare utilization burden. However, this disorder often goes unrecognized and untreated due to a lack of formal screening in primary care. Local Problem: A mobile primary clinic serving an uninsured population that is predominately Latino with limited English proficiency did not have a consistent PTSD screening process. Clients whose screening score was positive for possible PTSD did not have a consistent followup that included a brief intervention and referral for treatment. Interventions: The purpose of this Doctor of Nursing Practice project was to pilot the implementation of the Primary Care PTSD Screen (PC-PTSD) in either English or Spanish and provide a brief intervention with referral for treatment (PTSD SBIRT) in the patient’s preferred language. This project was implemented over a period of 15 weeks via the PTSD SBIRT protocol. The inclusion criteria for those screened included all newly admitted patients age 18 or older with no cognitive impairment and the ability to understand and speak English or Spanish. The estimated sample size (n=36) for the pilot period was based on the average rate of three new patient admissions per week over 12 weeks. The University of Maryland Baltimore Institutional Review Board gave a Non-Human Subjects Research determination for project implementation. Results: The total number of new patients meeting the inclusion criteria was 46 (n=46). The percentage of new patients screened was 97.8% (n=45). Of those screened, 6.7% (n=3) had a positive screen score, and 100% of patients with positive screening received the brief intervention with referral for treatment. Some barriers to the project implementation included scheduling conflicts, initial staff resistance, lack of protocol clarity, and confusion over the fourth item of the Spanish PC-PTSD. The main facilitators of the project were collaboration between project leader and staff, staff’s proactivity with communication, ease of screen use, and high compliance rate. Conclusions: The PC-PTSD was an easy tool to administer, interpret, and incorporate within the intake process of the mobile primary care unit. The project highlighted the lack of available treatment resources for this patient population. After the pilot period, the project leader met with the director and staff to discuss sustainability of the protocol for new admissions and to begin implementation annually for current patients. The mobile clinic director made plans to integrate the PTSD SBIRT protocol into their electronic health record with modified item-4 in the Spanish PC-PTSD. The clinic director’s goal is to continue integrating screenings with regular practice as a means to advance primary care behavioral health integration, increase mental health awareness, and improve population health outcomes through enhanced quality of care.
    • Increasing Human Papillomavirus Vaccination Rates Among Adolescents in Primary Care

      Hodge, Rachel E.; Hoffman, Ann G. (2020-05)
      Problem and Purpose: Each year, 33,700 men and women in the United States are diagnosed with a cancer caused by infection from the human papillomavirus (HPV), 90% of which could have been prevented through vaccination. Despite the proven safety and effectiveness of this vaccine, rates of uptake are low nationwide, a mere 53.7% for females and 48.7% for males. The purpose of this quality improvement (QI) project was to implement and evaluate interventions guided by the 4 Pillars™ for Practice Transformation Program, an evidence-based tool-kit shown to increase HPV vaccination rates across settings, including in primary care. Methods: A bundle of interventions was implemented using the 4 Pillars Program. Pillar 1 Convenience and Easy Access: all patient encounters of those aged 11-18 were used as an opportunity to vaccinate (not just well visits). Pillar 2 Patient Communication: providers issued a “strong recommendation” for the HPV vaccine using the Same-Way Same-Day strategy from the Centers for Disease Control and Prevention (CDC). Pillar 3 Enhanced Vaccination Systems: Immunization status was assessed as part of vital signs and Vaccine Information Statements (VIS) were given to all eligible patients’ parents. Pillar 4 Motivation: progress toward improving HPV vaccination rates was tracked and posted in staff break room. Results: Implementation of this tool-kit resulted in an increase in the HPV vaccination rate from 68% to 76.6%, an 8.6% increase (p<0.01). 100% of patients presenting for 11-year-old well child checks were vaccinated (n=32). 100% of eligible patients were given VIS and immunization status was assessed as part of vital signs for 100% of patient encounters. There was no real gender difference discovered in the final HPV vaccination rate. Among males (n=521), there was a 78% final rate and 76% for females (n=574), echoing the closing of the gender gap nationwide. 15 patients who previously refused, consented and were vaccinated. Conclusion: This QI project demonstrated this vaccination tool-kit is an effective way to increase HPV vaccination among adolescents in primary care.
    • Screening for Depression in a Rural Primary Care Setting

      Wallander, Jacquelyn C.; Yarbrough, Karen (2020-05)
      Problem and Purpose: The United States Preventative Services Taskforce recommends depression screening in the general adult population. Patients with untreated depression have higher morbidity rates in many diagnosis groups. Detecting and managing depression allows patients to better self-manage chronic diseases and contributes to an overall sense of improved well-being. In a private primary care setting a practice gap existed in which patients were not routinely screened for depression. The purpose of this quality improvement (QI) project was to implement a screening process for adults in a primary care practice to detect depression symptoms and offer treatment if indicated. Methods: The primary aim of this QI project was to implement a depression screening process for adults in a primary care practice using the Patient Health Questionnaire-9 (PHQ-9), a validated depression screening instrument. Primary outcomes measured: provider compliance in obtaining depression screenings and calculating the percentage of patients identified with depression. Eligible patients were aged 18-64 being seen for an annual exam with two Nurse Practitioners (NP). The NPs were provided PHQ-9 education and weekly reminders to complete the screening. During each patient annual exam, the patient was provided a copy of the PHQ-9. The NP reviewed results and treated when indicated. Charts were audited weekly for: provider compliance and depression classification. Results: Depression screening compliance was 67%, (n=30/45) and 30% of patients screened (n=9/30) were diagnosed with depression. All depressed patients were offered treatment. 20% were new depression diagnoses (n=6/30) and 10% had a history of depression (n=3/30). 13% (n=4/30) of patients were provided referrals to psychotherapy and 7% (n=2/30) were started on a medication for depression. The majority of the positive depression screenings (67%, n=6/9) were detected as mild. Conclusion: Depression screening using the PHQ-9 instrument is an effective way to detect depression. This will reduce the untreated depression rates in the practice and connect patients to proper treatment. Once depression is managed, patients are able to better self-manage chronic diseases. Implementation of the PHQ-9 into the provider workflow will increase depression screening compliance. As a result of this project, the primary care practice built the PHQ-9 instrument into the electronic health record to facilitate provider compliance.
    • Screening for Depression in Primary Care Practice

      Ruff, Sarah; Scrandis, Debra (2019-05)
      Background Ineffective screening of depression in primary care practice contributes to the number of patients with poor quality of life and mismanaged care, leading to fatalities and higher healthcare costs to repair the system brokenness. Primary care providers have a leading role in communicating patient information, such as risk for depression and treatment options, National guidelines and goals exist for providers to effectively screen the general adult population for depression, in order to provide appropriate care and help patients to avoid suicide, implementing a standardized screening tool can improve patient outcomes and reduce costs in primary care practice, Local Problem Ineffective screening of depression was an observed and verbalized practice problem at a primary care doctor's office in a suburban location of Maryland. The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the Patient Health Questionnaire-9 (PHQ-9) as a standardized screening tool to increase the detection of depression and appropriate treatment options for the general adult population. Interventions This quality improvement project occurred over a total of 14 weeks, including eight weeks of an implementation phase, During the first two weeks, a medical doctor and two medical assistants at a primary care office were instructed on how to implement and score the PHQ-9. The primary provider was also educated on the proposed treatment actions. The project leader assessed facilitators and barriers, and randomly selected patient charts of participants to review for data collection. Pender's Health Promotion Model (HPM) was used to guide this practice change. Results During the implementation phase, the primary me provider reported observing an increase in the number of patients diagnosed with depression, referred to psychiat7, and/or treated with a new antidepressant, based on PHQ-9 results. A significant number of adult patients completed the PHQ-9 questionnaire, while a smaller sample size was randomly selected for further data analysis (n= 95), Based on the ease of implementation and improved detection rates of depression, the staff within this primary care office continued to administer the PHQ-9 beyond the implementation phase. Results were saved within the patients' electronic health record. Conclusion Ineffective screening for depression in primary care practice continues to lead to adverse events. National guidelines supporting use of the PHQ-9 are recommended but not required for the general adult population. The large number of questionnaires administered during the implementation phase of this project was both a benefit and limitation, considering the extent of data analysis is to be completed in a short timeframe. Other limitations included the small number of staff involved and at two-week outage of the electronic health system in this office. Sustainability of this project may be obtained, as key stakeholders accept the organizational changes, benefit from the cost savings, and continue to improve quality of life.
    • Stopping Elderly Accidents, Deaths and Injuries: Fall Prevention for Community-Dwelling Older Adults

      Neser, Sarah B.; Rowe, Gina C. (2020-05)
      Problem & Purpose: Falls are the leading cause of death due to injury among older adults, yet most older adults who fall fail to report falling to their provider. Lack of routine fall screening and management among community-dwelling older adults places them at risk for future falls and injuries. The purpose of this 12-week quality improvement project was to implement the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries protocol in a primary care office to screen older adults for falls and address modifiable risk factors for those at increased risk. Methods: A literature review supported the protocol in reducing falls among older adults. Publicly available resources were adapted into training presentations and case scenarios for providers and staff. Staff screened eligible older adults during their office visit. Providers assessed gait and balance for those with a positive screen and identified fall risk (low, moderate or high). Moderate- and high-risk patients received a risk assessment and fall plan of care. Protocol steps were recorded on checklists reviewed weekly by the project leader to evaluate protocol adherence. Ongoing chart reviews, case scenarios, and a mid-project training session reinforced the protocol. Data was analyzed in three four-week time intervals with a goal of 80% adherence to all protocol steps. Results: The majority of protocol steps remained above goal over all time intervals or improved with training. All moderate- and high-risk patients received a fall care plan, despite risk assessments dropping below goal in the final interval. Moderate-risk patients were difficult to correctly identify. Overall protocol adherence was highest for low-risk patients (97%) and lowest for high-risk patients (80%) compared to moderate-risk (81%). Conclusion: With continued staff education and protocol reinforcement, the Stopping Elderly Accidents Deaths and Injuries protocol can be successfully implemented in the primary care daily workflow. Protocol adherence may be complicated by fall risk level. This project’s results support the 2019 modified protocol in removing stratified risk levels. Barriers to implementation include lack of protocol reimbursement and time to complete the protocol. Future studies should assess effectiveness of the protocol in reducing falls at one-year follow-up.
    • Substance Screening, Brief Intervention, and Referral to Treatment in Rural Primary Care

      Johnson, Kabrina L.; Fornili, Katherine (2020-05)
      Problem: Providers in a small, rural primary care practice in rural Maryland reported higher rates of alcohol or drug use disorders over the past several years, consistent with county-level data. The lack of screening tools and referral resources was identified as a need (Carroll County Sheriff Office, 2017). Purpose: SBIRT is a comprehensive early intervention approach that includes universal substance screening (S), and depending on problem severity, providing either brief interventions (BI) or referrals to treatment (RT) (SAMHSA, 2019). Methods: Medical assistants (MA) conducted a pre-screen using the first 3 items of the Alcohol Use Disorders Identification Test (AUDIT) and the National Institute on Drug Abuse (NIDA) single item drug screen. For those with positive pre-screens, medical providers completed full screens, using the remaining 7 items of the AUDIT, and the Readiness Ruler to assess for use of other substances and readiness to change. Results: Of 290 eligible patients seen over 10 weeks, 68.6% received a pre-screen. Reasons for missed pre-screens were “too busy” (27.4%); high patient census that day (29.6%) or no MA on duty (42.8%). N=38 patients (19.1%) had a positive pre-screen; all scoring >8 on the full AUDIT received a BI for alcohol misuse (n=6, 15.7%) or an RT for probable alcohol dependence (n=1, 2.6%). All with a positive drug screen (n=4, 2.0 %) received a BI. Low rates of screening may be due to short duration of implementation; low patient census; staffing issues, and possibly, patient under-reporting of substance use. Conclusions: Organizational leadership and physician involvement is necessary for SBIRT implementation. Primary care practices adapting SBIRT into their workflow should implement universal screening with validated, standardized substance use screening tools. SBIRT implementation should be conducted as a team approach. To help alleviate potential time constraints, medical assistants can be utilized to conduct SBIRT screening. SBIRT implementation can help primary care staff increase their knowledge of alcohol and drug use in their patient population and help to reduce the associated stigma.
    • Utilization of Written Asthma Action Plan In a Pediatric Primary Care Setting

      Efunbajo, Grace; Hoffman, Ann G. (2020-05)
      Problem: Asthma is a common and potentially serious chronic disease that affects over 20 million adults and 6 million children in the United States. Pediatric standard of care supports providing an asthma action plan to asthma patients/families. The use of asthma action plans (AAP) has been associated with improved asthma patient outcomes. Studies have shown poor utilization of AAP by healthcare providers for promoting self-management and self-efficacy. Purpose: The purpose of this DNP quality improvement project was to implement and evaluate the use of personalized written asthma action plans by healthcare providers in a pediatric primary care setting. Methods: The project was implemented over a 13-week period beginning in September of 2019. Participants were existing and newly diagnosed asthma patients less than or equal to 21years old who were receiving care for sick visits or annual physical examination. The conceptual framework of the project was based on Kurt Lewin’s change theory. In addition, a 4-hour education and training on asthma and the importance of the AAP was given to the healthcare providers (a physician and nurse practitioner), the office manager, and supporting members of staff. Healthcare providers and medical assistants were equally trained on how to complete an asthma action plan. The change process included the use of a colored paper asthma action plan and medical assistants provided the AAP sheet with a completed demographic section of the tool before the medical provider completed the other sections. Results: During the implementation period, data were collected on the number of AAP’s completed by the healthcare providers. This information was aggregated through a chart audit of de-identified copies of completed AAP’s. Run charts were used for data analysis. The clinic achieved 90% of AAP utilization rate, which surpassed the 60% goal of the project. Conclusion: The implementation and utilization of a written asthma action plan and in-service training in a pediatric outpatient setting improves patient accessibility to a treatment plan by primary care healthcare providers. The use of an evidence-based AAP can enhance patient management of asthma by giving patients and caregivers a roadmap to asthma care.
    • Written Asthma Action Plan Implementation and Evaluation in Pediatric Primary Care

      Roberts, Courtney O.; Satyshur, Rosemarie D. (2021-05)
      Problem & Purpose: Asthma guidelines recommend the use of written asthma action plans (WAAPs) in the management of pediatric asthma patients, but this is not always practiced in the primary care setting (Global Initiative for Asthma [GINA], 2019; National Asthma Education and Prevention Program [NAEPP], 2007; Ring et al., 2015). Lack of proper asthma management can lead to an increase in asthma related unscheduled sick visits. The purpose of this quality improvement project is to implement and evaluate a WAAP for pediatric asthma patients in a pediatric primary care clinic in the Eastern Shore Maryland area. Methods: Implementation of a WAAP involved one pediatrician, two pediatric nurse practitioners, and the pediatric patients between the ages of 1 to18 years old being seen for asthma management. The project took place at a pediatric primary care clinic on the Eastern Shore Maryland beginning August 31, 2020 and concluding on December 11, 2020. Early on, staff were educated on the WAAP via email that included a recorded PowerPoint presentation as well as a post-test, instructional asthma videos, a WAAP template, and the Asthma Quick Reference Guidelines pdf. After implementation began, weekly chart audits assessed WAAP utilization. Data collected were organized using Excel sheets. Run charts were created and updated weekly to trend the data. Flyers were created and disseminated in the in the office to encourage staff and patient engagement. Weekly WAAP update emails were sent out to staff to update them on the progress of the project. No personal patient or provider information was collected for this quality improvement project. Humans Research Protections Office (HRPO) approval was gained through the University of Maryland. Results: All eight staff members completed the staff education before September 15. The WAAP utilization goal was met, and 100% of asthma patients being seen were given a WAAP by week fifteen. Unscheduled sick visits decreased to 0% by week fifteen. Conclusion: This quality improvement project demonstrated that WAAP utilization by providers for pediatric asthma patients can decrease unscheduled sick visits.